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Wawrzoniak T, Romańska J. Effect of Serial Clinical Observation Complemented by Point-of-Care Blood Culture Volume Verification on Antibiotic Exposure in Newborns. Glob Pediatr Health 2024; 11:2333794X231226057. [PMID: 38269318 PMCID: PMC10807344 DOI: 10.1177/2333794x231226057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 12/09/2023] [Accepted: 12/18/2023] [Indexed: 01/26/2024] Open
Abstract
Objective. This study evaluated the effects of serial clinical observation strategy complemented by point-of-care verification of blood culture volume in managing term and near-term newborns at risk for early-onset sepsis. Methods. We used a "before-and-after" approach. Infants born at ≥35 0/7 weeks' gestation were eligible. Our strategy was based on serial clinical observation complemented with point-of-care verification of blood culture volume. Two separate 12-month periods were analyzed. The number of infants exposed to antibiotics started during the first 3 days of life was compared before and after introducing the strategy. Results. During the post-intervention period, 0.6% of infants received antibiotic therapy, compared to 4.1% during the pre-intervention period (P < .001; relative risk [RR]: 0.15; 95% CI: 0.08-0.28). Conclusion. Serial clinical observation complemented with verification of blood culture volume might reduce antibiotic utilization in newborns in the early postnatal period.
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Guan G, Joshi NS, Frymoyer A, Achepohl GD, Dang R, Taylor NK, Salomon JA, Goldhaber-Fiebert JD, Owens DK. Resource Utilization and Costs Associated with Approaches to Identify Infants with Early-Onset Sepsis. MDM Policy Pract 2024; 9:23814683231226129. [PMID: 38293656 PMCID: PMC10826394 DOI: 10.1177/23814683231226129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 12/21/2023] [Indexed: 02/01/2024] Open
Abstract
Objective. To compare resource utilization and costs associated with 3 alternative screening approaches to identify early-onset sepsis (EOS) in infants born at ≥35 wk of gestational age, as recommended by the American Academy of Pediatrics (AAP) in 2018. Study Design. Decision tree-based cost analysis of the 3 AAP-recommended approaches: 1) categorical risk assessment (categorization by chorioamnionitis exposure status), 2) neonatal sepsis calculator (a multivariate prediction model based on perinatal risk factors), and 3) enhanced clinical observation (assessment based on serial clinical examinations). We evaluated resource utilization and direct costs (2022 US dollars) to the health system. Results. Categorical risk assessment led to the greatest neonatal intensive care unit usage (210 d per 1,000 live births) and antibiotic exposure (6.8%) compared with the neonatal sepsis calculator (112 d per 1,000 live births and 3.6%) and enhanced clinical observation (99 d per 1,000 live births and 3.1%). While the per-live birth hospital costs of the 3 approaches were similar-categorical risk assessment cost $1,360, the neonatal sepsis calculator cost $1,317, and enhanced clinical observation cost $1,310-the cost of infants receiving intervention under categorical risk assessment was approximately twice that of the other 2 strategies. Results were robust to variations in data parameters. Conclusion. The neonatal sepsis calculator and enhanced clinical observation approaches may be preferred to categorical risk assessment as they reduce the number of infants receiving intervention and thus antibiotic exposure and associated costs. All 3 approaches have similar costs over all live births, and prior literature has indicated similar health outcomes. Inclusion of downstream effects of antibiotic exposure in the neonatal period should be evaluated within a cost-effectiveness analysis. Highlights Of the 3 approaches recommended by the American Academy of Pediatrics in 2018 to identify early-onset sepsis in infants born at ≥35 weeks, the categorical risk assessment approach leads to about twice as many infants receiving evaluation to rule out early-onset sepsis compared with the neonatal sepsis calculator and enhanced clinical observation approaches.While the hospital costs of the 3 approaches were similar over the entire population of live births, the neonatal sepsis calculator and enhanced clinical observation approaches reduce antibiotic exposure, neonatal intensive care unit admission, and hospital costs associated with interventions as part of the screening approach compared with the categorical risk assessment approach.
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Affiliation(s)
- Grace Guan
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
| | - Neha S. Joshi
- Department of Pediatrics, Center for Academic Medicine, Stanford University, Stanford, CA, USA
| | - Adam Frymoyer
- Department of Pediatrics, Center for Academic Medicine, Stanford University, Stanford, CA, USA
| | - Grace D. Achepohl
- Stanford Prevention Research Center, Stanford University, Palo Alto, CA, USA
| | - Rebecca Dang
- Department of Pediatrics, Center for Academic Medicine, Stanford University, Stanford, CA, USA
| | - N. Kenji Taylor
- Division of Primary Care & Population Health, Stanford University School of Medicine, Stanford, CA, USA
- Roots Community Health Center, Oakland, CA, USA
- Intermountain Health Care, Intermountain Health Delivery Institute, Salt Lake City, UT, USA
| | - Joshua A. Salomon
- Department of Health Policy, School of Medicine, and Stanford Health Policy, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, USA
| | - Jeremy D. Goldhaber-Fiebert
- Department of Health Policy, School of Medicine, and Stanford Health Policy, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, USA
| | - Douglas K. Owens
- Department of Health Policy, School of Medicine, and Stanford Health Policy, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, USA
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Mazabanda López DA, Taboada Rubinos C, Hernández Ortega A, Pérez Guedes LDM, Urquía Martí L, García-Muñoz Rodrigo F. Management of neonates with 35 weeks of gestational age or more with infectious risk factors at birth: opportunities for improvement. J Perinat Med 2022; 50:1150-1156. [PMID: 35533646 DOI: 10.1515/jpm-2021-0372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 04/10/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The Northern California Kaiser-Permanente Neonatal Sepsis Risk Calculator (SRC) has proved to be safe and effective in reducing laboratory tests, hospital admissions, and administration of antibiotics to patients at risk of early-onset neonatal sepsis (EONS). Many studies have focused on maternal chorioamnionitis as the principal risk factor for EONS. We wanted to know if the use of the SRC could be equally efficient in the context of several other infectious risk factors (IRF), in addition to chorioamnionitis, such as intrapartum maternal fever, GBS colonization and/or prolonged rupture of membranes (PROM). METHODS Systematic study of neonates with ≥35 weeks gestational age (GA), born in our tertiary university hospital during a period of 18 months. Patients were retrospectively assessed with the SRC and its recommendations were compared with the actual management. A bivariate analysis of perinatal interventions, and outcomes was performed. RESULTS A total of 5,885 newborns were born during the study period and 1783 mothers (31%) had at least one IRF. The incidence of culture-proven EONS was 0.5‰. The use of the SRC would have reduced laboratory evaluations (CBC and CRP) from 56.2 to 23.3%, and blood cultures, hospital admissions and antibiotic therapy from 22.9 to 15.5%, 17.8 and 7.6%, respectively. The management based on patients' symptoms would have shown a reduction to 7.5% in all the outcomes of interest. CONCLUSIONS Both, the SRC and the management based on clinical findings, are safe and efficient to reduce the number of analytical studies, hospital admissions and administration of antibiotics to neonates with IRF.
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Affiliation(s)
- Diego Andrés Mazabanda López
- Division of Neonatology, Hospital Universitario Materno-Infantil de Las Palmas, Las Palmas de Gran Canaria, Spain
| | - Carla Taboada Rubinos
- Division of Neonatology, Hospital Universitario Materno-Infantil de Las Palmas, Las Palmas de Gran Canaria, Spain
| | - Andrea Hernández Ortega
- Division of Neonatology, Hospital Universitario Materno-Infantil de Las Palmas, Las Palmas de Gran Canaria, Spain
| | - Lucía Del Mar Pérez Guedes
- Division of Neonatology, Hospital Universitario Materno-Infantil de Las Palmas, Las Palmas de Gran Canaria, Spain
| | - Lourdes Urquía Martí
- Division of Neonatology, Hospital Universitario Materno-Infantil de Las Palmas, Las Palmas de Gran Canaria, Spain
| | - Fermín García-Muñoz Rodrigo
- Division of Neonatology, Hospital Universitario Materno-Infantil de Las Palmas, Las Palmas de Gran Canaria, Spain
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Initiative to Reduce Antibiotic Exposure of Asymptomatic Infants Born to Mothers with Intraamniotic Infection. Pediatr Qual Saf 2021; 6:e480. [PMID: 34589654 PMCID: PMC8476054 DOI: 10.1097/pq9.0000000000000480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 06/09/2021] [Indexed: 11/22/2022] Open
Abstract
Infants born to mothers with intraamniotic infection (IAI) received antibiotic treatment per the Centers for Disease Control and Prevention and American Academy of Pediatrics guidelines in our neonatal intensive care unit (NICU) for early-onset bacterial sepsis evaluation. We conducted a quality improvement project to decrease antibiotic use and NICU admission in infants born to mothers with IAI.
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Gourishankar A, Agbasi A, Kain C, Lin E. Antibiotic exposure in hospitalized pediatric patients in the United States: prevalence and length of stay. Expert Rev Anti Infect Ther 2020; 18:1171-1175. [PMID: 32580590 DOI: 10.1080/14787210.2020.1787833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Hospital antibiotic use is rising. We aimed to evaluate the antibiotic-use prevalence and length of stay. METHODS We conducted a single-center retrospective study of patients < 18-years-old admitted to general pediatric services who received ≥ 1 antibiotic over six months. Demographics, culture results and antibiotic details were collected. The primary outcome was to identify the total number and classes of antibiotics prescribed during the admission. Secondary outcomes included length of stay (LOS), culture results, and the most commonly used antibiotics. RESULTS Forty-eight percent of patients received monotherapy (single class antibiotic). Cephalosporins (55%), vancomycin (35%), and clindamycin (22%) were prescribed more commonly than other antibiotic classes. Children were exposed up to 4 classes of antibiotics (range 1-4). A moderate correlation existed between the length of stay and the number of antibiotic classes used (R2 = 0.38). Two or more classes of antibiotic use prolonged the length of stay. Cephalosporin use was associated with 35% reduced LOS (95 CI, 21%-57%), and penicillin use correlated with 38% more prolonged LOS (95 CI, 22%-66%). CONCLUSIONS Antibiotic use in pediatric hospitals was high, and children received multiple classes of antibiotics. Inappropriate antibiotic use and culture results may have an untoward effect on hospital length of stay.
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Affiliation(s)
- Anand Gourishankar
- Pediatric Hospital Medicine, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, USA
| | - Angela Agbasi
- Department of Pharmacy, Children's Memorial Hermann Hospital , Houston, TX, USA
| | - Courtney Kain
- Department of Pharmacy, Children's Memorial Hermann Hospital , Houston, TX, USA
| | - Ellen Lin
- Department of Pharmacy, Children's Memorial Hermann Hospital , Houston, TX, USA
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Schulman J, Benitz WE, Profit J, Lee HC, Dueñas G, Bennett MV, Jocson MAL, Schutzengel R, Gould JB. Newborn Antibiotic Exposures and Association With Proven Bloodstream Infection. Pediatrics 2019; 144:peds.2019-1105. [PMID: 31641017 DOI: 10.1542/peds.2019-1105] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To estimate the percentage of hospital births receiving antibiotics before being discharged from the hospital and efficiency diagnosing proven bloodstream infection. METHODS We conducted a cross-sectional study of 326 845 live births in 2017, with a 69% sample of all California births involving 121 California hospitals with a NICU, of which 116 routinely served inborn neonates. Exposure included intravenous or intramuscular antibiotic administered anywhere in the hospital during inpatient stay associated with maternal delivery. The main outcomes were the percent of newborns with antibiotic exposure and counts of exposed newborns per proven bloodstream infection. Units of observation and analysis were the individual hospitals. Correlation analyses included infection rates, surgical case volume, NICU inborn admission rates, and mortality rates. RESULTS The percent of newborns with antibiotic exposure varied from 1.6% to 42.5% (mean 8.5%; SD 6.3%; median 7.3%). Across hospitals, 11.4 to 335.7 infants received antibiotics per proven early-onset sepsis case (mean 95.1; SD 71.1; median 69.5), and 2 to 164 infants received antibiotics per proven late-onset sepsis case (mean 19.6; SD 24.0; median 12.2). The percent of newborns with antibiotic exposure correlated neither with proven bloodstream infection nor with the percent of patient-days entailing antibiotic exposure. CONCLUSIONS The percent of newborns with antibiotic exposure varies widely and is unexplained by proven bloodstream infection. Identification of sepsis, particularly early onset, often is extremely inefficient. Knowledge of the numbers of newborns receiving antibiotics complements evaluations anchored in days of exposure because these are uncorrelated measures.
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Affiliation(s)
- Joseph Schulman
- California Department of Health Care Services, California Children's Services, Sacramento, California;
| | | | - Jochen Profit
- NICU, Lucile Packard Children's Hospital, Stanford, California.,Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and.,California Perinatal Quality Care Collaborative, Stanford, California
| | - Henry C Lee
- NICU, Lucile Packard Children's Hospital, Stanford, California.,Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and.,California Perinatal Quality Care Collaborative, Stanford, California
| | - Grace Dueñas
- NICU, Lucile Packard Children's Hospital, Stanford, California.,Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and.,California Perinatal Quality Care Collaborative, Stanford, California
| | - Mihoko V Bennett
- NICU, Lucile Packard Children's Hospital, Stanford, California.,Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and.,California Perinatal Quality Care Collaborative, Stanford, California
| | - Maria A L Jocson
- California Department of Health Care Services, California Children's Services, Sacramento, California
| | - Roy Schutzengel
- California Department of Health Care Services, California Children's Services, Sacramento, California
| | - Jeffrey B Gould
- NICU, Lucile Packard Children's Hospital, Stanford, California.,Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and.,California Perinatal Quality Care Collaborative, Stanford, California
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Joshi NS, Gupta A, Allan JM, Cohen RS, Aby JL, Kim JL, Benitz WE, Frymoyer A. Management of Chorioamnionitis-Exposed Infants in the Newborn Nursery Using a Clinical Examination-Based Approach. Hosp Pediatr 2019; 9:227-233. [PMID: 30833294 DOI: 10.1542/hpeds.2018-0201] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Antibiotic use in well-appearing late preterm and term chorioamnionitis-exposed (CE) infants was reduced by 88% after the adoption of a care approach that was focused on clinical monitoring in the intensive care nursery to determine the need for antibiotics. However, this approach continued to separate mothers and infants. We aimed to reduce maternal-infant separation while continuing to use a clinical examination-based approach to identify early-onset sepsis (EOS) in CE infants. METHODS Within a quality improvement framework, well-appearing CE infants ≥35 weeks' gestation were monitored clinically while in couplet care in the postpartum unit without laboratory testing or empirical antibiotics. Clinical monitoring included physician examination at birth and nurse examinations every 30 minutes for 2 hours and then every 4 hours until 24 hours of life. Infants who developed clinical signs of illness were further evaluated and/or treated with antibiotics. Antibiotic use, laboratory testing, and clinical outcomes were collected. RESULTS Among 319 initially well-appearing CE infants, 15 (4.7%) received antibiotics, 23 (7.2%) underwent laboratory testing, and 295 (92.5%) remained with their mothers in couplet care throughout the birth hospitalization. One infant had group B Streptococcus EOS identified and treated at 24 hours of age based on new-onset tachypnea and had an uncomplicated course. CONCLUSIONS Management of well-appearing CE infants by using a clinical examination-based approach during couplet care in the postpartum unit maintained low rates of laboratory testing and antibiotic use and markedly reduced mother-infant separation without adverse events. A framework for repeated clinical assessments is an essential component of identifying infants with EOS.
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Affiliation(s)
- Neha S Joshi
- Department of Pediatrics, Stanford University, Stanford, California; and
| | - Arun Gupta
- Department of Pediatrics, Stanford University, Stanford, California; and
| | | | - Ronald S Cohen
- Department of Pediatrics, Stanford University, Stanford, California; and
| | - Janelle L Aby
- Department of Pediatrics, Stanford University, Stanford, California; and
| | | | - William E Benitz
- Department of Pediatrics, Stanford University, Stanford, California; and
| | - Adam Frymoyer
- Department of Pediatrics, Stanford University, Stanford, California; and
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Schulman J, Profit J, Lee HC, Dueñas G, Bennett MV, Parucha J, Jocson MA, Gould JB. Variations in Neonatal Antibiotic Use. Pediatrics 2018; 142:peds.2018-0115. [PMID: 30177514 PMCID: PMC6188671 DOI: 10.1542/peds.2018-0115] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2018] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVES We sought to identify whether and how the NICU antibiotic use rate (AUR), clinical correlates, and practice variation changed between 2013 and 2016 and attempted to identify AUR ranges that are consistent with objectively determined bacterial and/or fungal disease burdens. METHODS In a retrospective cohort study of >54 000 neonates annually at >130 California NICUs from 2013 to 2016, we computed nonparametric linear correlation and compared AURs among years using a 2-sample test of proportions. We stratified by level of NICU care and participation in externally organized stewardship efforts. RESULTS By 2016, the overall AUR declined 21.9% (95% confidence interval [CI] 21.9%-22.0%), reflecting 42 960 fewer antibiotic days. Among NICUs in externally organized antibiotic stewardship efforts, the AUR declined 28.7% (95% CI 28.6%-28.8%) compared with 16.2% (95% CI 16.1%-16.2%) among others. The intermediate NICU AUR range narrowed, but the distribution of values did not shift toward lower values as it did for other levels of care. The 2016 AUR correlated neither with proven infection nor necrotizing enterocolitis. The 2016 regional NICU AUR correlated with surgical volume (ρ = 0.53; P = .01), mortality rate (ρ = 0.57; P = .004), and average length of stay (ρ = 0.62; P = .002) and was driven by 3 NICUs with the highest AUR values (30%-57%). CONCLUSIONS Unexplained antibiotic use has declined but continues. Currently measured clinical correlates generally do not help explain AUR values that are above the lowest quartile cutpoint of 14.4%.
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Affiliation(s)
- Joseph Schulman
- California Children's Services, California Department of Health Care Services, Sacramento, California;
| | - Jochen Profit
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California;,Lucile Packard Children’s Hospital, Palo Alto, California;,California Perinatal Quality Care Collaborative, Stanford, California
| | - Henry C. Lee
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California;,Lucile Packard Children’s Hospital, Palo Alto, California;,California Perinatal Quality Care Collaborative, Stanford, California
| | - Grace Dueñas
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California;,Lucile Packard Children’s Hospital, Palo Alto, California;,California Perinatal Quality Care Collaborative, Stanford, California
| | - Mihoko V. Bennett
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California;,Lucile Packard Children’s Hospital, Palo Alto, California;,California Perinatal Quality Care Collaborative, Stanford, California
| | - Janella Parucha
- California Perinatal Quality Care Collaborative, Stanford, California
| | - Maria A.L. Jocson
- California Children’s Services, California Department of Health Care Services, Sacramento, California
| | - Jeffrey B. Gould
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California;,Lucile Packard Children’s Hospital, Palo Alto, California;,California Perinatal Quality Care Collaborative, Stanford, California
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What's the harm? Risks and benefits of evolving rule-out sepsis practices. J Perinatol 2018; 38:614-622. [PMID: 29483569 DOI: 10.1038/s41372-018-0081-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 01/08/2018] [Accepted: 01/22/2018] [Indexed: 02/08/2023]
Abstract
Asymptomatic term and late-preterm newborns with risk factors for early onset sepsis commonly undergo laboratory evaluation and receive empiric antibiotic therapy. Some have challenged the rationale for current "rule-out sepsis" practices, arguing that they lead to unnecessary overtreatment and healthcare costs. A series of recent clinical studies has explored scheduled serial observations as an alternative to laboratory testing and empiric antibiotics for asymptomatic newborns with historical risk factors for sepsis. These studies have shared the conclusion that serial observation is safe and cost-effective for well-appearing term and late-preterm babies, but they are also somewhat speculative because culture-proven early onset sepsis is an extremely low prevalence diagnosis. Here, we review the evolving consensus of optimal rule-out sepsis practices. We examine chorioamnionitis as an example of a problematic risk factor that has contributed to the controversy surrounding this topic. We also discuss how introduction of online sepsis risk calculators has allowed more precise delineation of a patient's chances of developing culture-proven infection. Finally, we analyze existing data from published studies to estimate the number needed to harm (NNH) when an observation-based strategy is used instead of a risk-based approach. We conclude that, if harm is defined as death or serious sepsis complications such as hemodynamic instability or neurologic injury, the NNH is 1610, compared to an NNH of 7 and 2.9 for IV infiltrates and delayed breastfeeding, respectively-two common and potentially consequential complications of NICU admission for a rule-out sepsis. We believe that the differential between risk of serious harm from observing a well-appearing term or late-preterm newborn with risk factors for sepsis and the risk of less significant but common NICU complications argues in favor of the ongoing trend toward less aggressive management of newborns with sepsis risks.
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